In Peru, The Critical Battle Against TB Is Behind Bars

25/03/2017 7:55 AM AEDT
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Updated
29/03/2017 2:07 AM AEDT

Hiob via Getty Images

Hiob via Getty Images

A physician working in Lurigancho Prison in Lima, Peru once explained to me, “Prisons like Lurigancho function like a society in miniature. There’s a distribution of powers, of hierarchies, of priorities, and of necessities.” Throughout the five months I spent working on a tuberculosis research team in Lurigancho in 2015, TB clinic staff emphasized learning about the prison’s conditions and social structures. For clinic staff, knowledge of the prison’s inner workings was fundamental to their jobs – you couldn’t understand Lurigancho’s TB epidemic without understanding Lurigancho’s world.

Yet understanding life in Lurigancho is no small feat. The prison’s daily operations are chaotic, primarily because of overcrowding. Lurigancho was built to accommodate 3,204 prisoners but now consistently incarcerates more than 8,000 prisoners, making it by far Peru’s largest prison. The prison has the aura of a bustling urban center because prisoners are largely free to walk throughout the precincts during the day – the shortage of guards means prisoners’ daily lives are relatively flexible.

The shortage of paid staff also means prisoners are, by necessity, deeply involved in maintaining order and sustaining general operations. Prisoners man internal checkpoints and own the restaurants and kiosks that sell food (the prison has a vibrant money-based economy). The 21 pavilions that house Lurigancho’s prisoners each have an elected leadership structure (la delegatura) headed by a prisoner (el delegado) who interfaces with prison authorities.

Our research team’s main project involved administering questionnaires to TB patients about their treatment experiences. As in non-prison settings, TB treatment in Lurigancho was hard because of its lengthy duration, the medications’ side effects, and patients’ additional struggles with loneliness, drug addiction, HIV co-infection, and depression. The prison also presented TB patients with the difficult task of completing treatment in a uniquely chaotic environment.

Tuberculosis in Peru and Lurigancho

Lurigancho’s struggle with TB is one part of Peru’s broader epidemic. Peru has the second highest incidence of TB in the Americas after Haiti, and its struggle against TB is all the more harrowing because of its especially high burden of multidrug-resistant TB (MDRTB). While Peru has reduced its number of new TB cases over the years, the battle against TB remains daunting.

Prisons like Lurigancho are major flashpoints in Peru’s anti-TB battle. A range of factors – including extensive overcrowding, insufficient ventilation and lighting, and poor nutrition – make prisons hotbeds for TB transmission. In 2013, the rate of TB in the country’s prisons was 26 times higher than in Peru’s general population. In Lurigancho, the cycle of transmission produces approximately 450 new identified TB cases each year.

The doctors and nurses in Lurigancho’s TB clinic are always stretched thin when providing care to hundreds of patients. This means that, as in the prison’s overall operations, prisoners are deeply involved in Lurigancho’s tuberculosis program. Prisoners known as colaboradores help with many of the administrative tasks associated with the program, like filing patient records. Other prisoners known as promotores raise awareness of TB among prisoners, gather sputum samples from suspected new cases for testing, and find patients who don’t report for observed dosing of their medication (i.e., directly observed therapy (DOT)). The doctors and nurses always emphasized to me that the TB program would be unsustainable without the prisoners’ help.

Protocols for TB treatment in Lurigancho are standardized. All newly diagnosed patients live in a dedicated tuberculosis pavilion, Pavilion 17, during the first few months of treatment. Once prisoners are no longer contagious (usually after three months), they return to their original pavilions. These prisoners are instructed to report daily to an established site for DOT.

Some patients try to avoid taking the medications because of their many side effects. Nurses would speak to me of prisoners who hid pills under their tongue and later spit them out or otherwise feigned taking them. Other prisoners don’t show up to take their medications and have to be located by promotores.

Ultimately, abandonment of treatment is rare among prisoners – the enclosed prison environment makes it hard to fall through the cracks of the prison’s anti-tuberculosis network. Yet while abandonment is rare, irregular treatment is more common. Irregular treatment is a risk factor for developing MDR-TB. In a country that struggles with MDR’TB, irregularity is cause for concern.

Bridging Epidemics: Lurigancho and New Tactics in Peru’s Anti-TB Strategy

In general, I didn’t go to Lurigancho on Wednesdays. Wednesdays are visit days, when prisoners’ loved ones are allowed to enter the prison for the space of three or four hours. When I finally did go to the prison on a visit day, I found Lurigancho transformed. Outside, merchants lined the streets with carts selling food and other wares. Thousands of people had flocked to Lurigancho and formed an endless line to enter the prison’s precincts. The prison’s population, I was told, could swell to 14,000 people on a Wednesday.

Peru’s health ministry talks about “bridge populations” when discussing tuberculosis in prisons. Guards, clinic staff, and visiting loved ones can all transport tuberculosis and other diseases from the prison to the broader community and vice versa. The throngs of people on a visit day underline the fact that TB in Lurigancho is not isolated from Peru’s broader epidemic. The situation with TB in Lurigancho has consequences for broader Peruvian society.

Responding to the bridges between the two epidemics, Peru’s government declared a health emergency in the country’s prisons in January 2017. The decree includes proposals for greater investment in penitentiary healthcare. It also recognizes the contribution of overcrowding to the TB epidemic in Peru’s prisons and proposes constructing additional prisons as one solution. The director of Peru’s penitentiary division (INPE) also plans to reduce overcrowding by releasing less serious first-time offenders with electronic trackers.

Part of the reason Lurigancho’s clinical staff emphasized learning about Lurigancho’s conditions and social structures was because of Lurigancho’s unpredictability. As a provider, you needed to understand the inner workings of the prison to provide care through events like a change in a pavilion’s delegado or a police raid for contraband.

But during my time working in Lurigancho, the root causes of Lurigancho’s TB epidemic were often viewed as constants. Issues like overcrowding, inadequate ventilation, and poor nutrition were clearly key to addressing the TB epidemic, but funding and political momentum weren’t usually adequate to effect change. Even when the support did materialize, it eventually waned. Lurigancho’s TB clinic team was left wary of initiatives that seemed evanescent.

I’m holding out hope that the new decree will bolster Lurigancho’s fight against tuberculosis. It’s encouraging to see increased awareness of how much is at stake in Lurigancho’s current stalemate with TB. If the new initiatives address root causes of the epidemic in Lurigancho’s “society in miniature,” Peru can win substantial ground against TB in Peruvian society at large.

This post is part of the ‘Tuberculosis Today’ series produced by The Huffington Post highlighting the challenges of combatting TB. Tuberculosis is now back in the top ten causes of death globally, and it is the world’s leading infectious disease killer despite being curable and preventable.